Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036060508 | IL |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 036060508 | IL |
NPI | 1164479424 |
---|---|
Provider Name | Dr. Charles W Lagoski |
First Address | Breese, IL 62230-3510 |
Second Address | Peoria, IL 61636-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2006 |
Last Update Date | 17/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036060508 | (05) | IL |
B54404 | (02) | IL |